School-based deworming: A planner’s guide to proposal development for national school-based deworming programs Conference Ready Edition Produced by Deworm the World with input from: The Partnership for Child Development, the World Bank, the Education for All–Fast Track Initiative, the World Health Organization, the World Food Programme, the Ministries of Health and Education in The Gambia, Kenya, Liberia, Nigeria and Sierra Leone, Innovations for Poverty Action, Kenya Medical Research Institute, and Helen Keller International. © Deworm the World 2010 All rights reserved. Permission to reproduce any part of this document is required. Please contact: Deworm the World 1000 Thomas Jefferson Street NW Washington, D.C. 20007, USA. Telephone: +1-202-403-5714. Fax: +1-202-403-5994. Email: [email protected] For further information on worm control in school-age children please visit the following websites: www.dewormtheworld.org; www.schoolsandhealth.org; and www.who.int/wormcontrol/en/ How to use this guide This guide is intended to assist policymakers and planners in proposal writing and initial design for national school-based deworming programs. It is also a detailed aid for construction of an accompanying budget. Based around 8 Steps for developing a school-based deworming program the guide highlights all the key pieces of information which will be needed at the planning and proposal stage and how they should be used in designing the program. When planning a school-based deworming program or writing a proposal each step should be addressed and the relevant information sought. Where information or action is not available or concluded, the proposal and plan should include next steps for completion. The 8 Steps for developing a school-based deworming program Step 1: Developing a policy framework. Step 2: Targeting school-based deworming. Step 3: Procuring and distributing deworming tablets. Step 4: Training of teachers. Step 5: Community sensitization. Step 6: Sequencing of implementation. Step 7: Monitoring and evaluation. Step 8: Preparing a budget. Rather than being prescriptive, the guide provides a template for planning. It draws from and includes two detailed case studies of school-based deworming scale up which demonstrate implementation strategy for the 8 Steps and their adaption to fit unique country settings. The step by step overview of school-based deworming programs is the entry point for a suite of technical assistance packages available through Deworm the World, the Partnership for Child Development (PCD), the World Health Organization (WHO), and other development partners. The packages which can support policymakers at each stage are listed in the Resources section along with notes on applying for funding, and a checklist for good practice. Contents Why school-based deworming? 1 8 Steps to school-based deworming 4 Case studies 23 Resources 33 Glossary and abbreviations 43 References 47 Why school-based deworming? Over 400 million school-age children worldwide are infected with parasitic worms. These infections harm their health and development, and limit their ability to both access and benefit fully from the education system. In 2001, WHO set the goal of treating 75% of school-age children at risk of infection by 2010. However, by the fall of 2006, only 10% of these children were receiving regular treatment. There is a safe, simple, and cost-effective solution: school-based deworming. It has been shown to reduce absenteeism by 25%, and at less than 50 US cents per child per year, school-based deworming is one of the most cost-effective methods of improving school participation ever rigorously evaluated. In pursuit of achieving the Education for All (EFA) and the Millennium Development Goals (MDGs), Ministries of Education, United Nations agencies, the World Bank, and civil society organizations have made school-based deworming an education policy priority. The overwhelming effects of school-based deworming are a crucial step towards achieving universal global education. If there are any best buys or “silver bullets” to support progress in meeting these goals, then school-based deworming is surely one. 1 • Worms affect both the health and education of children During a period of both intense physical growth and learning, school-age children suffer the highest burden of worm infections and, consequentially, the greatest morbidity (see Figure 1) (Bundy et al. 1992a; Bundy et al. 1992b). The two types of worms that most commonly affect children are schistosomes (also known as bilharzia) and soil-transmitted helminths (STH), which include roundworm, whipworm, and hookworm. Worms affect children’s health, potentially causing: • Anemia. • Malnourishment. • Impairment of mental and physical development (Hotez et al. 2006; Stephenson 1987). Short term, children with worms may be too sick or tired to attend school or to concentrate. Long term, like under nutrition, worms are associated with: • Impaired cognitive development and decreased educational achievement (Simeon and Grantham-McGregor 1990; Mendez and Adair 1999). • Poor performance on cognitive function tests which delays reaction times (Watkins and Pollitt 1997). • Poor short term memory (Jukes et al. 2002). Even longer term it is estimated that: • Infection leads to an average IQ loss of 3.75 points per child. • Children persistently infected with hookworm are less likely to be literate (13%) and earn less as adults (43%) than those who grow up free of worms (Bleakley 2007). Figure 1: The intensity of worm infection is greatest in schoolchildren. 2 • School-based deworming contributes to the achievement of EFA School-based deworming alleviates or prevents the many health impacts mentioned, and by doing so contributes to: • Reduction of absenteeism (Miguel and Kremer 2004). • Increased potential to learn (Grigorenko 2006). • Having the greatest impact on the neediest children. School-based deworming is pro-poor. • School-based deworming is cost-effective • The estimated cost for school-based deworming is less than 50 US cents per child per year, inclusive of teacher training, drug procurement and distribution (PCD, 1999). • Compared with other education interventions, mass school-based deworming is an extremely cost-effective method of improving school participation (J-PAL, 2005; Bundy et al. 2006). • Treating only school-age children reduces the total disease burden due to worm infections in the community by reducing the number transmitting infection. • Delivery through schools by teachers is effective and feasible • As the health sector may prioritize the needs of pregnant women and under-fives, and as a proven education intervention, school-based deworming should be a priority for the education sector. • The best way to reach large numbers of school-age children is through the existing infrastructure of schools and community links of teachers. • Where prevalence is high WHO recommends regular mass treatment of schoolchildren (Montresor et al. 2002) without the need for individual diagnosis. • Deworming tablets are cheap and effective with minor side-effects, so with little training teachers can safely and easily administer them. Figure 2: Cost-effectiveness of different education interventions. Note: In this analysis, basic school health services primarily include deworming. 3 8 Steps to school-based deworming 4 STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 STEP 6 STEP 7 STEP 8 Preparing a budget Training of teachers Training Community sensitization Monitoring and evaluation Sequencing of implementation Developing a policy framework Developing a policy Targeting school-based deworming Targeting Procuring and distributing deworming tablets STEP 1 Developing a policy framework A strong policy framework that supports school-based deworming is critical to the development of a systematic and sustainable national program. Endorsement by high level officials from the relevant ministries enables effective action at all levels during the planning and implementation stages. Key to the success of any school-based deworming program is the partnership between the Ministries of Education and the Ministries of Health, and key policy decisions to be made include the joint identification of roles and responsibilities for each element of the program. Key processes 1. Objectives of the program should be defined, this will provide the context for school-based deworming.They should support and build upon existing School Health and Nutrition strategy and policy. 2. Strategic partnership on school health and nutrition should be developed between the Ministries of Education and Health as well as with other stake holders such as the United Nations World Food Programme (WFP), the United Nations Children’s Fund (UNICEF), and non-governmental organizations (NGOs). This should include mapping and coordinating any current activities which are occurring. 3. A memorandum of understanding (MoU) should be drawn up between the Ministries of Health and Education to define which areas of the program each have responsibility for. While it is tempting to assign tasks to ‘both’, division of responsibility should be made where possible according to ministerial roles and expertise. A draft MoU is available from Deworm the World. 4. A Joint Committee or Task Force can be formed to oversee and coordinate the processes, and take the program forward as a unified education and health endeavor. 5. A Policy for Action should finally be developed specifically for school-based deworming. This should be based